How Our Army In France Can Avoid The Menace of Tuberculosis

By S. Adolphus Knopf, M.D.

[The Nation; January 10, 1918]

[This article is a revised presentation of an address delivered by invitation before the American Public Health Association at its last session in Washington, in October, 1917, and published by authority of the Surgeon-General in a number of medical journals in the United States and Canada. Prof. William H. Welch, Dean of Johns Hopkins Medical School, says of the original address: "Everything possible must be done to protect our soldiers from the risks of tuberculosis, and I believe that the public may be assured that this will be done. "Undoubtedly the education of the individual soldier is an important part of these efforts, and your address is an important contribution to this end." Surgeon-General Blue, of the United States Public Health Service, has suggested that this information should appear in pamphlet form in a vest-pocket edition for our soldiers, while Mary O. Nelson, one of our most experienced tuberculosis nurses, now working in France as head nurse of the Rockefeller Tuberculosis Commission, suggests the publication of the article in English and French together, to be given to every American soldier now in France. Some of the division surgeons of our camps have asked for several thousand copies. The United States Printing Bureau in Washington is overwhelmed with work and cannot undertake anything additional at this time. Will not some philanthropist come forward and place at the disposal of our Government the funds for the printing -and widest possible distribution of such an information pamphlet?]

In two remarkable articles, published in the Survey of May, 1917, and in the Evening Post of December 22, Dr. Hermann M. Biggs gives some alarming figures on tuberculosis in France. "The number of soldiers," he says, "discharged
from the French army because of tuberculosis has been estimated at about 150,000." To this number Dr. Biggs adds 1½ per cent of cases of the disease in various stages in the active army, which would make 20,000 more cases. In addition to these two groups, there are 110,000 active cases in the civilian population of France, besides the unnumbered thousands among French prisoners, military and civil, still in Germany, who, because of privation and want,
physical and mental suffering, have fallen victims to the disease. I am inclined to agree with Dr. Biggs that in all probability half a million cases of tuberculosis will have to be dealt with in France after the war.

While we hope and pray that the war may not last long, and that a victorious peace for the Allies may soon be concluded, we must bear in mind that many of our own boys now are and many more will be in France, and that we must do everything possible to protect them from the risks of tuberculosis. We should impart to the American soldiers in the field and also to our French brethren in arms as much knowledge as possible concerning tuberculosis, its causes and prevention, so that they may be able victoriously to fight this insidious and invisible enemy, just as they are fighting the visible powers which have plunged the world into the present indescribable catastrophe.

Fortunately, the experience of the past twenty-five years has taught us much that can be done to protect the individual from contracting tuberculosis. We now know the character of the disease. We have instituted popular
anti-tuberculosis education. Through the training of young physicians in the early diagnosis of tuberculosis, timely recognition of the disease has been made more nearly universal. Lastly, proper hospital and sanatorium provision for the cure and care of those afflicted with the disease has been made by nearly all the American municipalities. These means of prevention and cure have made the United States rank next to England as the country with the lowest tuberculosis morbidity and mortality of all the great nations of the world; and we must see to it that our soldiers have the simple information needful to guard them against
this dread disease.

Every soldier should know that pulmonary tuberculosis is a chronic, infectious, communicable, preventable, and curable disease. In characterizing the disease I have replaced the word "contagious" by the word "communicable,"
because contact per se, that is to say, touching the tuberculous, does not convey the disease, as is the case with smallpox, for example. If the tuberculous patient is careful in the disposal of his expectoration and in the manner of coughing, he is as safe an individual to associate with as anybody else. Such a one should never be shunned, but always treated kindly, considerately, and with compassion.

The direct cause of tuberculosis, or consumption, is always the bacillus of tuberculosis, which is a microscopic organism found in the affected parts of the body. Pulmonary tuberculosis, or tuberculosis of the lung, is the type of tuberculosis most commonly found, and the type with which the French soldiers are now so frequently afflicted. All other organs of the body (bones, intestines, etc.) can also become affected with tuberculosis.

The word tuberculosis comes from tubercle, which signifies a small rounded body, resembling a pin head and easily visible to the naked eye. The bacilli are lodged in these tubercles, of which they cause the formation. These germs give off certain poisonous substances called toxins which cause the symptoms of pulmonary tuberculosis, early as well as late. The earlier symptoms, which can be easily recognized by the layman, are a long-continued cough with or without expectoration or hoarseness, loss of flesh, flush or pallor in the face, feverish sensations in the afternoon, occasional night sweats, chilly sensations in the morning, loss of appetite, sometimes a little streak of blood in the expectoration, loss of strength manifesting itself in easy tiring, frequent colds, a perceptible quickening of the heart beats after slight exertion, a little change in disposition, such as an increased irritability or a feeling of depression.

The three methods by which the germ may enter the human system are by inhalation, ingestion, and inoculation. The main method of contracting tuberculosis is by inhaling dried, infectious tuberculous dust floating in the air coming from carelessly deposited sputum. Whoever coughs and expectorates, whether it be in the trenches, dugouts, barracks, tents, armories, or other confined places, should endeavor not to deposit the sputum where it has a chance to dry up, unless it can be where exposure to direct sunlight will render it harmless. When a person coughs, let him always hold his hand before his mouth. He will thereby avoid infecting others by inhalation-infection or droplet-infection if he should happen to be afflicted with tuberculosis, influenza, measles, or even an ordinary cold. By droplet infection is understood that manner of conveying the disease by the spray of small particles (droplets) of infectious saliva during the so-called dry cough or even sneezing, and in some individuals during excited speaking.

Against the danger of tuberculous food in the form of infected milk or meat, sterilising or boiling the milk and thoroughly cooking or broiling the meat suffice for all practical purposes. Eating and drinking utensils should never be "swapped," and they should always be thoroughly, cleaned before use. To protect one's self against getting tuberculous inoculation from any skin wound or scratch, it is best to let the wound bleed freely so as to wash away any infectious substances and then use a clean piece of cheese-cloth muslin, dipped in hot water or alcohol, and tie up the wound until surgical aid can be obtained.

Numerous as are the causes whereby tuberculosis may be contracted, more is needed to contract tuberculosis than the accidental inhalation of a few tuberculous germs or the occasional ingestion of tuberculous food. In good health the human system is provided with various means of defence against the invasion of the tuberculosis bacilli, such as the mucous membrane of the nose which has a germ-killing property, the white blood corpuscles which in health are
always active in destroying the dangerous bacteria that may have entered the body, and the secretions of the stomach, to which also must be ascribed bacteria-killing properties.

In order to contract tuberculosis in the ways before mentioned, there must be the conditions in which the tuberculosis germs can grow, or, in other words, one must be predisposed either by heredity or acquisition. This predisposition can be inherited when the mother was tuberculous at the time of pregnancy, but the inheritance in turn may have been overcome because of the good care bestowed upon the child. Many such a one has grown up strong and well, and if he has not had tuberculosis by the time he has reached military age, and no disease has been discovered by the recruiting surgeon, he may safely consider himself free from danger of developing tuberculosis if he leads what might be simply called a normal healthy life.

The predisposition to tuberculosis may be acquired through having had certain diseases which often leave the system in a weakened condition: among them are measles, whooping-cough, typhus and typhoid fever, grippe, chronic
bronchitis, pleurisy, pneumonia, and all venereal diseases. Privation, want of food, lack of air and sunlight, insufficient clothing, and the prolonged inhalation of irritating substances, as well as over-fatigue and lack of sleep, may also make the system susceptible to tuberculosis. Excessive smoking, especially of cigarettes when the smoke is inhaled, is apt to injure the respiratory system and make it more susceptible to disease, to weaken the action of the heart, impair the function of the nervous system, and lessen the general efficiency. One who has never smoked would better not acquire the habit. One of the greatest predisposing causes to tuberculosis is the excessive use and abuse of
alcoholic drink. When the alcoholic contracts tuberculosis, the outlook for a cure is not nearly so favorable as in a man of temperate habits. Patients recovering from the above-mentioned diseases should be particularly careful to avoid
prolonged contact with tuberculous individuals.

The soldier in the field can do much for himself to guard against becoming predisposed to tuberculosis. Besides refraining from the use of liquor, strong alcoholic drinks, and from all other excesses, he should, as far as possible, eat
regularly, keep his body clean, and rest when he can so as to avoid over-fatigue. He should keep his bowels in good condition and drink plenty of good, pure water. He should also try to clean his teeth after meals whenever this is
feasible. When his garments have become wet from rain or snow, he should not lie down and sleep in them if this can possibly be avoided, and he should be equally careful not to lie down on the moist ground without sufficient protection.
But, of course, on the firing lime and in trenches and dugouts these precautions cannot often be carried out, and one must do the best one can.

If the air in the dugouts and trenches seems to be vitiated, that is to say, foul and lacking oxygen, whenever the circumstances will permit, the soldier should go where the air is pure and take some deep breathing exercises. The
simplest one of all is to inhale deeply through the nose, raising the shoulders during the act of inhalation, moving them backward and remaining in that position, retaining the air for about five or six seconds, and then to exhale a trifle more quickly while moving the shoulders forward and downward. This exercise may be taken from six to eight times, and, if convenient, repeated after half an hour or an hour.

If the dugouts and trenches can be ventilated so as to admit fresh air, this should by all means be done. In tents and barracks and all other sleeping quarters the soldier should, of course, make it his business to see that there is
plenty of ventilation. Fresh air by day and by night is their best preventive as well as curative agent of this disease.

To prevent the spread of tuberculosis, the soldier should bear in mind the early symptoms which have been described. If he coughs and expectorates, he should gather a specimen of his sputum and take it to the doctor for examination. Meanwhile he should use all the precautions possible, that is to say, spit in a piece of cloth or in a receptacle rendered harmless by some antiseptic fluid like a 5 per cent carbolic acid solution, which he should empty into the trench latrine or drain. During the cough he should hold his hand before his mouth, and he should never swallow his expectoration. These precautions about expectoration should be especially observed when soldiers, after leaving the trenches temporarily or permanently, are billeted in peasants' houses in villages or citizens' homes in city or town.

If the soldier perceives any of the symptoms earlier described, he need not think at once that he has tuberculosis, but it is his duty as a soldier to report his condition immediately to the surgeon in charge of his company. He will then be carefully examined and proper care will be taken of him. If the ailment is not tuberculosis, the examination will demonstrate this; if it is tuberculosis, the early diagnosis and timely treatment will save the individual's life, for it should be known that of all the chronic diseases human flesh is heir to none offers so favorable a chance for cure as does pulmonary tuberculosis if discovered early.

Provided with this education concerning the prevention of tuberculosis neither the American soldier in France not his loved ones at home need greatly fear his contracting the disease, in spite of its alarming frequency among the civilian and military population of France. Even before the war the death-rate from tuberculosis was twice as high in France as in New York City; while in France there were, in each year, three deaths from tuberculosis per thousand of population. France had to mobilize a great army and had to do it quickly. The thorough physical examination so essential for the discovery of tuberculosis could not be made, and thus many a young man strongly disposed had to enter the army in defence of his country. While military life even in trenches and dugouts may be conducive to the increase of strength and vigor in the normal and healthy individual, the stress and strain of the soldier's life in war time, long marches, life in trenches and dugouts, and the actual work on the firing line, will develop an active tuberculosis in the strongly predisposed or in those already afflicted with incipient tuberculosis, and often at an alarmingly rapid rate.

This must be the explanation for the great frequency of tuberculosis among the fighting soldiers of France. All the sad conditions which predispose the individual to tuberculosis either by heredity or custom, and those which are acquired through privation, want, lack of food and air, and through physical and mental suffering have combined to increase the number of tuberculous individuals throughout the civilian population of that country. Fortunately for the American soldier, his early training in the open of fresh air and the use of cold water on his body have made him naturally more resistant to the disease, and to the honor of our military surgeons, it must be said that the examinations at the recruiting offices are most thorough, so that those who are strongly disposed to tuberculosis, or already afflicted with the disease in the incipient stage, are weeded out. The examination is repeated after a few month's training so as to make sure that no tuberculous invalid is in active service. Yet the possibility that some of our soldiers may develop tuberculosis must be admitted; but even if this should occur, if the American boy now serving under arms of France will remember his obligation to his comrades. To himself, to his country, and to his allies, and will take the simple precautions here suggested, he will not be in great danger of the disease and will be well taken care of if he should get it.

But the American soldier now in France can also do a good deal to help in the fight against tuberculosis and diminish its frequency among his French comrades as well as in the civilian population with whom he may come in contact. Most French people and not a few Americans still fear the night air and are too much afraid of draughts, believing them to be most dangerous and the cause of catching cold. First of all, the practice of sleeping with the windows open at night in winter as well as summer should be taught by example, by word of mouth, and by printed instructions; but in France this must be done with tact so as not to offend. People should be made to realize that night air is as good as day air, and even purer, for as a rule there is less traffic, less commotion, and less dust in the air at night. Draughts are dangerous to the individual only when he has perspired and the pores of his skin are open; at all other times draughts
are beneficial, since air currents and winds tend to purify the atmosphere. Under ordinary conditions colds are not contracted from draughts, but are due to infection just as much as is tuberculosis.

Another way in which the American soldier may help the French in combating tuberculosis is by helping overcome the prejudice so common in France against drinking water. Next to fresh air there is no greater factor in keeping a man well and strong than a plentiful ingestion of pure water. AA moderate quantity (about a glassful) with meals and two glasses between meal times in most conducive to good health.

The Rockefeller Foundation has sent to France a Tuberculosis Commission composed of expert diagnosticians, sanitarians, and trained nurses under the leadership of Prof. Livingston Ferrand, the former executive secretary of the National Association for the Study and Prevention of Tuberculosis. They will combine with the American Red Cross and the French authorities to do all that can be done for the French civilian population. From Colonel Dercle, of the Medical Department of the French army, now attached to the Surgeon-general's office in Washington, I have learned that heroic efforts are being made to provide hospital and sanatorium facilities for the tuberculous of the French army. It is therefore my hope that through all these agencies and the knowledge of how to protect one's self and others from contracting the disease, a knowledge which should become the property of American and French soldier, the tuberculosis situation in France may be speedily ameliorated.

Prevention is better than cure, but we must also be prepared ere long to receive back some of our boys who may have contracted tuberculosis and must be prepared to cure them. Many of our private and municipal sanatoria have
offered to receive and care for any American soldier who may return home having contracted tuberculosis on the field of honor. We hope that there may be fewer tuberculous invalids in need of sanatorium treatment among our soldiers
than are found among the same number of the civilian population; but at all events the American public may rest assured that our American soldiers now fighting in France who may contract tuberculosis will receive the best and most
scientific treatment known to the medical profession to-day.

Lastly, one more word of hope for the future. What may we look for regarding the tuberculosis problem in all civilized countries after the successful issue of this war of democracy against autocracy? The Power which upheld
the maxim Might makes Right, which, disregarding the will of the people, plunged them into a war of indescribable horror, will be dethroned and banished. There will be a united Europe as there is a united America. When democracy shall be universal, the countless millions of dollars which the warring nations now have to sacrifice for weapons of destruction will be devoted to purposes of construction. Tuberculosis, which is as much a social as a medical disease, will
decrease with the betterment of the social conditions of the masses, and medical science, now in the main devoted to healing the wounds of war, can then once more devote its energies to the prevention of disease. All other sciences now utilized for war will likewise be consecrated to the advancement of human happiness and health, and with these blessings attained, tuberculosis, the great white plague and enemy of mankind, will gradually disappear.